HLTC05_Lecture_4.docx

HLTC05 –Social Determinants of Health
Lecture 4: Social Inequality and Health
Tuesday, October 2, 2012
Explaining the Inequality –Ill Health Connection
 Three Hypotheses (see Nguyen and Peschard 2003) :
1. Social cohesion: clinical epidemiological studies indicate that density of social networks correlates with better disease
outcomes and decreased mortality
o Better health, less health disparity
o Less social cohesion unequal
2. Psychosocial mechanisms: e.g., Stress as an entry point for harmful biological pathways – psychosocial mechanism
through which hierarchy exerts negative effects on human health
o Any type of stress acts as entry point for harmful health
o Eg., Lose your job you end up with a lot of stress about income and supporting family
o Prolonged type of stress
3. Material factors: material deprivation leads to poor health,
o i.e., via fewer investments in infrastructure, social services; more “stuff” shields you from environmental,
behavioural and social risks; material deprivation in childhood perpetuates “unhealthy” behaviour later in life
o Material deprivation of poverty (WHO: 40% of world’s population; live on US$2/day or less) is what is “unhealthy
o Inadequate housing and/or transportation
o Not have the basic things to protect us
Quiz # 1: Material factors in human health do not include:
a) Housing and support groups
b) Employment and income and sanitation
c) Private transportation and food
d) Clothing and medicines
Important Themes
 Structural violence
o How we view ill health
 Historical dynamics that produce inequality
 Anthropology of the body (commodification)
o We have to view ill health as just a biological product
o People sell parts of the body such as vital organs
o Made a body another thing to trade
 Notion of risk (and blame)
o Linking micro to macro, local to abroad
o How globalization affects an individual
 Linking local context to broader analysis, i.e., materialist factors placed within a broader geopolitical context;
globalization, macroeconomics
 Role of therapeutic systems (biomedicine) in fortifying inequalities/social hierarchies
o Biomedical vs. social health on disease
o Development of drugs
o Acts a structural violence
 Spiralling “illness poverty trap” (adverse health impact of inequalities exacerbates those very inequalities; poverty
produces ill health which worsens poverty)
o Being poor makes you sick which makes you more poor
 important role of ethnography (linking policy with everyday life)
o practice of ethnography
 very effective way we can think about micro macro linkage to globalization and a person’s ill health
 having a case study to help people relate to it Nguyen and Peschard (2003)
 The body is fashioned by cultural, political, and historical processes
o Not just a biological entity with basic epidemiological
 To better understand how social relations condition relative disease patterns, we must view the human body as deeply
historicized and socialized
o Not just biological statistics
o Not just cause or effect, but the complexity of historical and other factors
Socioeconomic Status
 Refers to a hierarchical structure that represents wealth, power (social, economic, political) and social prestige
o Can indicate inequality
 Measured by factors such as occupation, income (very common), education (esp. women)...
 Individuals with higher SES tend to have better outcomes: higher academic achievement, better physical and mental
health, increased literacy and decreased mortality rates
 This “gradient effect” of SES with outcome is evident in all developed, industrial societies
 It persists throughout the lifespan, thus kids born into low SES households tend to have poorer outcomes, even if they
have higher SES later in life
o Because of negative influences that happened in early life, especially during infancy and childhood
o Likely due to the sensitivity of the developing brain to its environment during infancy and childhood
 The Gradient Effect – Individuals with high SES have better
outcomes than those with low SES. Figure adapted from McCain,
Mustard and Shanker (2007)
 Furthermore, the Gradient Effect entails that even with same
absolute level of income, an individual in a more egalitarian
society (equality) will be healthier than one in a less egalitarian
society (inequality disparity)
 Gradient effect impacts health across all income levels
o Disparity and inequality within the society
o Less disparity, less social disparity and vice versa
 Now recognize that social inequality contributes to ill health
independently of income level
Biological Clear consequences due to gradient effect (there’s many more)
 Infant and Maternal Mortality
 Adult life Expectancy
 Cardiovascular Disease
 Blood Pressure Diabetes  Reflects maternal education
 No maternal education = higher infant mortality rate
 Maternal education reflects SES Proximate Causes
 Immediate cause for something
 Maternal education: infant mortality is higher in one group of women who are uneducated
Ultimate Causes
 beyond the reason, factor behind nutrition
 Example: structural violence
Structural Violence
 A term broadly describing unjust, aberrant and corrupt social structures characterized by poverty and extensive social
inequality, including racism and gender inequality
 Structural violence is violence exerted systematically - that is, indirectly (and directly) - by everyone who belongs to a
certain social order (Farmer 2004)
o we’re all part of it, we accept it, which makes its more daunting
 Reflected in differences in morbidity and mortality (TB, malaria, HIV) (Farmer 1997)
o Seen globally
o Diseases of poverty (e.g., HIV has a high prevalence in parts of Africa) reflects structural violence
 Structural violence is visible in the steep gradients of social inequality that, by producing severe poverty in an era of
increasing wealth (and